Updated: 7/25/2018

Variola

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Snapshot
  • As a dermatology resident, you are studying cutaneous manifestations of viral diseases. You come across a photo of a child with hundreds of pustular lesions, primarily on the face but also affecting the mucosa and the rest of the body. You realize that this was a disease resulting from a virus that is similar to the one causing chickenpox; however, it has been eradicated with global vaccination.
Introduction
  • Classification
    • variola
      • a poxvirus
      • an enveloped, linear, double-stranded DNA virus
  • Epidemiology
    • incidence
      • the disease has been eradicated with global vaccination
    • risk factors
      • bioterrorism
  • Pathogenesis
    • patients remain contagious until the lesion scabs and all scabs fall off naturally
  • Associated conditions
    • smallpox
  • Prevention
    • live-attenuated vaccine
  • Prognosis
    • mortality was very high with an overall fatality of 30%
Presentation
  • Symptoms
    • initial prodrome
      • fever and chills
      • headache
      • spinal pain
      • pharyngitis
      • may have a fine macular rash
    • characteristic rash occurs after prodrome
  • Physical exam
    • characteristic rash has 3 phases and is synchronous (i.e., all lesions are at the same stage of development)
      • initial small, red, non-blanching macules
        • develops into firm papules then into pustules and larger vesicles with central umbilication
      • affects both mucosa and skin but is denser on the face
      • lesions develop a scab by the second week
    • conjunctivitis
Studies
  • Labs
    • polymerase chain reaction assay
  • Electron microscopy
    • brick-shaped virions with internal dumbbell-shaped core containing viral DNA
    • from vesicular or pustular fluid
  • Making the diagnosis
    • based on clinical presentation
Differential
  • Varicella (chicken pox)
    • distinguishing factors
      • typically does not have a prodromal phase and begins with an exanthematous rash
      • progression from initial rash to scab is 7 days (vs 14 days in variola)
Treatment
  • Management approach
    • mainstay treatment is supportive care
    • patients should be isolated
  • Conservative
    • supportive care
      • indication
        • all patients
      • modalities
        • intravenous fluids
        • analgesics
        • good wound care
Complications
  • Cutaneous scarring
  • Encephalitis
  • Stillbirth
 

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